Pregnancy is a Magical Time of Life, Until it Hurts
Be fruitful, and multiply and replenish the earth…
According to National Vital Statistics Reports, Vol. 64, No. 12, December 23, 2015, Utah is number 1 at fulfilling this commandment. Which means more of Utah’s women are pregnant at any given time than anywhere else in the country. Needless to say we are multiplying and replenishing. Unfortunately multiplying and replenishing is not all sunshine and roses as the act of replenishing results in pregnancy. And the more replenishing one participates in the more time spent pregnant.
Unfortunately, a typical pregnancy results in fatigue and nausea for the first few months which makes it difficult to move, let alone participate in meaningful exercise. Once the initial feelings of illness pass, weight gain has already begun, which on average is 25-35 lbs. during a normal pregnancy. Then there’s the hormonal changes. As a male I have a difficult time relating to these changes but I often ask my patients why they would ever do this more than once. And the resounding answer is always, because it’s worth it.
Nearly 70% of pregnant women will experience significant low-back and pelvic pain during pregnancy. This is a natural result of altered biomechanics which leads to ligamentous strain, increased muscle tension and a decrease in range of motion, which can all lead to increased pain. This basically means that the bun in your oven is wreaking havoc on your supportive structures resulting in pain. This is not unlike an athlete with a repetitive use injury. Ongoing and increasing back and pelvic pain may result in an overall lack of productivity in your life. Unfortunately, the likelihood of greater pain and discomfort increases as your pregnancy progresses. Which, sadly can also result in chronic pain following your pregnancy.
At this point you should be asking yourself two questions. How can I prevent this from happening to me? And, what is a sports medicine doctor doing writing about pain in pregnancy? In answer to the latter question. I served for several years as the team physician for a division-1 university in Ohio where my office was located directly across the hall from a very busy OB/Gyn practice. It wasn’t long before I was asked if I could do anything for their many pregnant patients in pain. I jumped at the opportunity as this was a healthy and motivated patient population where prescription drugs are not generally acceptable. In general, expecting mothers are willing to endure just about any and all annoyances in order to protect and grow their babies. After seeing many of these pregnant women suffering with back and pelvic pain I soon learned that their painful conditions were not unlike the overuse injuries I was seeing in my collegiate and elite athletes.
Once pregnant a hormone called relaxin increases and peaks during the first 14 weeks of pregnancy and then peaks again near delivery. Relaxin is responsible for softening of the pelvic ligament which prepares the female pelvis for delivery of the baby. This is great for having babies but not awesome for activity as it results in laxity and shifting in the pelvis which results in pain. The most common complaints by pregnant women in my practice are low back pain, pelvic pain and hip pain. In my clinical experience the main pain generators associated with pregnancy are the large ligaments of the pelvis called the sacroiliac (SI) ligaments. Ligaments are very strong ropelike tissues that connect bone to bone or in other words, they hold the bones together. The SI ligaments are massive and connect the sacrum to the ilea forming the SI joint. In order to carry and deliver a baby, the sacroiliac ligaments have to soften allowing motion through the SI joint which results in widening of the pelvis. In normal conditions the SI joint transitions force from the legs to the rest of the body but during pregnancy they become softer allowing for some motion through the SI joints and this is when the problems begin.
Once the ligaments become soft the body will attempt to stabilize the SI joint by other means. It will first turn on the gluteal muscles and particularly the gluteus medius. The gluteus medius is a very powerful muscle that attaches the Ilium to the femur. Its job is to move the leg out and back. This is the muscle used to propel you forward while ice skating or rollerblading by pushing out and back. Thus not many hockey players end up with this type of pain. The gluteus medius will help stabilize the SI joint as long as it is able but as it was not designed for this work it will fail unless it was already strong to begin with. Failure of the gluteus medius results in pelvic and hip pain. It’s also interesting to note that it is not uncommon for a pregnant woman to complain of only hip and pelvic pain without low back pain.
So what’s to be done?
As with every other disease process, the best medicine is prevention. Being strong prior to pregnancy is always helpful. Pre-pregnancy training should be focused on core muscles with special attention given to the gluts. For the purpose of this discussion we will focus on what can be done when you are pregnant and in pain wishing you would have done some pre-pregnancy strengthening.
If you are pregnant and in pain, the focus will be on stabilization of the SI joint. As your pregnancy has progressed the primary stabilizers (ligaments) have become relatively unstable to accommodate the future delivery of your baby. Thus, you will need to focus on the secondary stabilizers (muscle) in order to maintain pelvic stability. Primary attention should be given to the gluteal muscles and particularly the gluteus medius. When I ask my pregnant patients if they are exercising, the reply is generally, yes. So I get more specific and ask what this means. The answers are usually, working around the house and walking. Both of which are good for overall health but do little to improve strength. The human body was built to walk and is very efficient at it. So, unless you are climbing hills, walking does not do much for strength. However, walking sideways does.
Generally, we all live in the North-South planes. We move in the forward (North) direction and spend very little time moving sideways or the East-West plane. If you find yourself in pain or want to prevent it during pregnancy the East-West plane is where you will want to spend some time in order to strengthen your gluts and stabilize your pelvis. Initially you will find that you are easily fatigued with movements in the East-West plane. Don’t get discouraged. This just means you have something to work on. Here are some simple, safe exercises you can do in order to decrease your pain related to pregnancy.
If you find yourself in the unfortunate but common condition of too much pain to even exercise you may require some attention prior to embarking on an exercise routine. Fortunately, there’s hope in the form of Osteopathic Manipulative Treatment (OMT) and physical therapy. OMT is the therapeutic application of manually guided forces by an Osteopathic Physician to improve physiologic function and/or support homeostasis that has been altered by your pregnancy. It has been shown in repeated studies that OMT is effective at reducing pain and improving function during pregnancy which may result in quicker recovery following delivery. The other option that has been successful at alleviating pain during pregnancy is a 12-week physical therapy program with specific focus on strength.
In conclusion, pregnancy should not result in a break from physical activity and strength training. Your ligaments will naturally loosen during pregnancy leaving your muscles to take up the slack. The stronger you are prior to pregnancy can prevent pain during pregnancy. However, if you find yourself pregnant at this time, it’s not too late to start some gentle strength training as outlined above. And, if you’re in too much discomfort to even exercise there’s hope in the form of OMT and physical therapy so don’t give up. Don’t let pain ruin the miraculous experience of pregnancy.